This field is hidden when viewing the form

Clinic Name(Required)

This field is hidden when viewing the form

Clinic Id

This field is hidden when viewing the form

Clinic Website

This field is hidden when viewing the form

Submitted URL

This field is hidden when viewing the form

Fax Number

This field is hidden when viewing the form

Clinic Phone Number

This field is hidden when viewing the form

X-Ray Walk In Hours

This field is hidden when viewing the form

Walk-In Only for X-Rays

This field is hidden when viewing the form

Calls Patient After Receiving Fax

This field is hidden when viewing the form

Internal Notes

This field is hidden when viewing the form

Procedure

Order Information

What brings you in today?

I need imaging for a symptom or health concern

I want a preventive or longevity screening

I'm looking for an elective pregnancy ultrasound

Other

Do you have a referral from a Provider?(Required)

I can upload my provider's referral.

My provider has the referral; I can't access it.

I don't have a referral and am self-referring.

Imaging Study Type(Required)

Body Part Requested(Required)

Have you been to this clinic before?(Required)

Yes

No

Not Sure

Imaging Order or Prescription(Required)

Please upload the imaging order you received from your doctor. Please include ALL 4 corners of the full page(s). It must include the name of the test and the ordering provider with their signature, otherwise we will be unable to schedule you. It can be a picture of the prescription from your phone. You can also upload any insurance approval or clinic documents.

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, bmp, tif, tiff, Max. file size: 10 MB, Max. files: 7.

Provider Full Name(Required)

Provider Phone Number(Required)

Provider Fax Number(Required)

Signature for Medical Records Release(Required)

By signing below, I authorize my provider to release their order to Expected Health and for the clinic I receive my procedure at to release my medical records to Expected Healthcare and to the provider I have listed.

This field is hidden when viewing the form

Would you like us to send the imaging results to your Provider?

Yes

No

Tell us a bit about yourself

Name(Required)

First Name Last Name

Your Email Address(Required)

Your Phone(Required)

Sex assigned at Birth(Required)

Male

Female

Date of Birth(Required)

Address(Required)

Street Address City State ZIP Code

Order Detail Information

Height (ft)(Required)

Weight (lbs)(Required)

Is the patient allergic to latex?(Required)

Yes

No

Does the patient have any allergies to any medications?(Required)

Yes

No

Please list the medications the patient is allergic to.(Required)

Does the patient have any mobility issues, such as a wheelchair?(Required)

Yes

No

Please explain any mobility issues the patient has

Secure Your Reservation

To reserve your appointment, please secure your slot with a credit card.

Credit Card

Card Details

Cardholder Name

Complete Your Appointment Request

Price:

Our fee covers coordinating your order, submitting to the Clinic and coordinating and securing an appointment on your behalf.

This field is hidden when viewing the form

Confirmation

This field is hidden when viewing the form

URL for extra file uploaded after submission

If a user uploads a file to their appointment request page after submission, this field will be populated with the URL of the uploaded file.

Order Information

Tell us a bit about yourself

Order Detail Information

Pregnancy Ultrasound

Mammogram Questions

Safety Information

Need to see a doctor fast?

Appointment Preferred Days & Times

Secure Your Reservation

Confirmation